Emergency. 2017; 5 (1): e56 OR I G I N A L RE S E A RC H Epidemiologic Features and Outcomes of Caustic Inges- tions; a 10-Year Cross-Sectional Study Athena Alipour Faz1, Fahimeh Arsan2, Maryam Peyvandi1, Mahbobeh Oroei3, Omid shafagh3, Maryam Yousefi1, Hassan Peyvandi3∗ 1. Clinical Research Development Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 2. General Surgery Department, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 3. Hearing Disorders Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Received: January 2017; Accepted: February 2017; Published online: 2 February 2017 Abstract: Introduction: Caustic ingestions are among the most prevalent causes of toxic exposure. The present 10-year survey aimed to evaluate the epidemiologic features and outcomes of caustic ingestion cases presenting to emergency department. Methods: This is a retrospective cross-sectional study on patients who were admitted to a referral toxicology center during 2004 to 2014, following caustic ingestion. Baseline characteristics, pre- senting chief complaint, severity of mucosal injury, complications, imaging and laboratory findings as well as outcomes (need for ICU admission, need for surgery, mortality) were recorded, reviewing patients’ medical pro- file, and analyzed using SPSS 22. Results: 348 patients with mean age of 37.76 ± 17.62 years were studied (55.6% male). The mean amount of ingested caustic agent was 106.69 ± 100.24 mL (59.2% intentional). Intentional in- gestions (p < 0.0001), acidic substance (p = 0.054), and higher volume of ingestion (p = 0.021) were significantly associated with higher severity of mucosal damage. 28 (8%) cases had died, 53 (15.2%) were admitted to ICU, and 115 (33%) cases underwent surgery. Conclusion: It seems that, suicidal intention, higher grade of mucosal injury, higher volume of ingestion, lower level of consciousness, lower serum pH, and higher respiratory rate are among the most important predictors of need for ICU admission, need for surgery, and mortality. Keywords: Caustics; epidemiology; toxicology; suicide, attempted; patient outcome assessment © Copyright (2017) Shahid Beheshti University of Medical Sciences Cite this article as: Alipour Faz A, Arsan F, Peyvandi M, Oroei M, shafagh O, Yousefi M, Peyvandi H. Epidemiologic Features and Outcomes of Caustic Ingestions; a 10-Year Cross-Sectional Study. Emergency. 2017; 5(1): e56. 1. Introduction C austic ingestions are among the most prevalent causes of toxic exposure. The most commonly in- gested caustics are acidic or alkaline substances (1). Ingestion of cleaning substances account for more than 200,000 annual exposures reported to the United States poi- son control center (2-4). 10% of adults referring with caus- tic ingestions expire and 1-2% of ingestions lead to stricture formation (5). Children younger than 5 years account for ap- proximately 80% of caustic ingestion cases that typically oc- cur accidentally. In adolescents, caustic ingestion cases are generally in an attempt to commit suicide and they present ∗Corresponding Author: Hassan Peyvandi; Hearing Disorders Research Cen- ter, Loghman Hakim Hospital, Makhsus St., Qazvin St., Tehran, Iran. Email: hassan.peyvandi@gmail.com Tel: 00982155419005 in more severe conditions (6, 7). Dysphagia, odynophagia, drooling, vomiting, stridor, dyspnea, and oropharyngeal le- sions are among the most important complaints of patients. Caustic ingestion can induce acute and chronic injuries and treatment in both stages is important. The severity of tis- sue injury in the acute phase depends on multiple factors in- cluding the type of substance, its concentration, the ingested amount, and the duration of contact (8). In the chronic stage, treatments concentrate on preventing development of strictures and improving function of the esophagus (9, 10). Loghman-Hakim toxicology center is one of the big referral centers for these injuries in Iran capital, Tehran. Therefore, the present survey aimed to evaluate the epidemiologic fea- tures and outcomes of caustic ingestion cases presenting to this center during a 10-year period. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com A. Alipour Faz et al. 2 2. Methods 2.1. Study design and setting This is a retrospective cross-sectional study on patients who were hospitalized in Loghman-Hakim Hospital, Tehran, Iran, during 2004 to 2014, following ingestion of caustic sub- stances. The study protocol was evaluated and approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences. All the information gathered was consid- ered confidential and was used anonymously throughout the study. Researchers adhered to all ethical principles presented in declaration of Helsinki during the study period. 2.2. Participants All patients who were admitted to the mentioned toxicology center following ingestion of caustic agents were enrolled us- ing census sampling. There was not any sex, age, ethnic or etc. limitation. Loghman-Hakim Hospital is one of the main referral centers for poisoning and intoxication emergencies in Iran and patients from all over the country are referred to this hospital. Therefore, this center hosts a diverse popula- tion of patients with various problems that can be considered as a national representative sample. 2.3. Data gathering Patients’ baseline characteristics (age, sex, clinical findings, intent of ingestion, type of caustic substance (acidic or alka- line), amount of ingested caustic (as reported by the patients or the patients’ family members), time to hospital, duration of hospitalization, duration of ICU admission), presenting vi- tal signs (systolic blood pressure, respiratory rate, pulse rate, Glasgow coma scale), presenting chief complaint (vomiting, dyspnea, drooling, etc.) severity of mucosal injury on esoph- agogastroduodenoscopy (EGD), gastrointestinal complica- tions (perforation, strictures and fistula formation), systemic complication (acute renal insufficiency and acute hepatic failure), chest x ray findings, pathology findings, and labora- tory findings (sodium, potassium, blood urea nitrogen, cre- atinine, aspartate aminotransferase (AST), alanine amino- transferase (ALT), blood gas analysis (pH, HCO3, PCO2)) as well as outcomes (need for ICU admission, need for surgery, mortality) were recorded reviewing patients’ medical profile. The severity of mucosal injuries was graded based on Zargar’s modified endoscopic classification (11). Patients with grade I burns are just monitored for 24 to 48 hours while patients with grade 2 and 3 undergo exploratory laparotomy (12-15). Acute renal insufficiency was defined as glomerular filtration Rate < 60 mL/min/1.73 M2 and acute hepatic failure as in- creased liver function tests to > 3 times the normal upper limit. A trained medical doctor was responsible for data gath- ering. 2.4. Statistical Analysis Data were analyzed using SPSS software for windows version 22. The quantitative data were described by mean ± standard deviation and qualitative variables were presented using fre- quency and percentage. The associations of baseline, clini- cal, and laboratory variables with need for surgery, need for ICU admission, and mortality were estimated using appro- priate statistical tests such as chi square, Fisher’s exact, t test, one way ANOVA, or non-parametric tests. The significance level was considered P < 0.05. Table 1: Baseline characteristics of studied patients Variable Value Age (year) < 18 25 (7.3) 18 – 35 144 (42) 35 – 50 97 (28.3) 50 – 65 39 (11.4) ≥ 65 38 (11.1) Sex Male 193 (55.6) Female 154 (44.4) Caustic type Acidic 188 (54.0) Alkaline 149 (42.8) Unknown 11 (3.2) Intention Suicidal 206 (59.2) Accidental 105 (30.2) Unknown 37 (10.6) Time to reach ED (hour) < 6 253 (81.87) 6 - 12 29 (9.38) >12 27 (8.73) Presenting signs Vomiting 164 (47.8) Hematemesis 145 (42.3) Dysphagia 88 (25.7) Drooling 68 (19.8) Oropharyngeal lesions 63 (18.4) Dyspnea 50 (14.6) History of suicidal attempt (n =78) Yes 47 (60.3) No 31 (39.7) History of psychiatric disorders (n =105) Yes 72 (68.6) No 33 (31.4) Vital signs on admission Systolic blood pressure (mmHg) 119.76±19.26 Pulse rate (/minutes) 86.29±14.72 Respiratory rate (/minute) 19.08±4.98 Glasgow coma scale 14.75±0.92 Data were presented as mean ± standard devia- tion or number and percentage. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com 3 Emergency. 2017; 5 (1): e56 Table 2: Laboratory findings of the studied patients at the time of admission to emergency department Variable Number (%) Sodium (mEq/dL) < 135 12 (3.6) 135 – 145 248 (74.7) > 145 72 (21.7) Potassium (mEq/dL) < 3.5 10 (3.0) 3.5 – 5.5 305 (91.9) > 5.5 17 (5.1) Blood urea nitrogen (mg/dl) < 20 48 (14.5) ≥ 20 284 (85.5) Creatinine (mg/dl) < 1.6 326 (96.1) ≥ 1.6 13 (3.9) Aspartate aminotransferase (U/L) < 40 56 (91.8) ≥ 40 5 (8.2) Alanine aminotransferase (U/L) < 40 57 (95.0) ≥ 40 3 (5.0) pH <7.35 85 (33.1) 7.35 -7.45 133 (51.8) >7.45 69 (15.2) HCO3 (mmol/L) < 22 128 (50.6) 22 – 26 75 (29.6) ≥ 26 50 (19.8) PCO2 (mmHg) <35 99 (28.4) 35 – 45 104 (40.8) ≥ 45 52 (20.4) 3. Results 3.1. Baseline characteristics 348 patients with mean age of 37.76 ± 17.62 years (3 – 87) were studied (55.6% male). Table 1 shows the baseline char- acteristics of studied patients. The mean amount of ingested caustic agent was 106.69 ± 100.24 mL (10 – 500). Hydrochlo- ric acid was the most commonly (69.8%) ingested acidic sub- stance, which was followed by sulfuric acid (19.5%). The most common ingested alkaline was lye (46.3%). Among in- tentional cases, 115 (56.1%) patients had used alkaline mate- rial and 90 (43.9%) acidic ones (p = 0.812). 3.2. Laboratory findings Table 2 summarizes the laboratory findings of studied pa- tients. 21.7% hypernatremia, 5.1% hyperkalemia, 3.9% ab- normal creatinine (≥ 1.6 mg/dl), and 8.2% abnormal liver function test were among the most important laboratory findings. Serum pH revealed 33.1% acidosis and 15.2% alka- losis. 3.3. Chest X ray findings 1 (0.5%) case of hemothorax, 2 (1.1%) sub-diaphragmatic free gas, 5 (2.7%) airway edema, 2 (1.1%) reticulonodular changes, and 2 (1.1%) aortic ectasia cases were among the most important chest X-ray findings, which were recorded for 186 cases. 3.4. Endoscopic findings The findings of EGD were available for 313 patients. The severity of esophageal mucosal damage based on Zargar’s modified endoscopic classification was normal in 64 (20.4), grade I in 133 (42.5%), grade IIa in 37 (11.8%), grade IIb in 16 (5.1%), and grade IIIa in 63 (20.1%) cases. These measures for gastric mucosal damage were 72 (25.9) normal cases, 72 (25.9%) grade I, 62 (22.3%) grade IIa, 32 (11.5%) IIb, 39 (14.0%) grade III, and 1 (0.4%) grade IV. Intentional inges- tions (p < 0.0001), acidic substance (p = 0.054), and higher volume of ingestion (p = 0.021) were significantly associated with higher severity of mucosal damage. 3.5. Pathology findings The results of pathological assessment were available for 49 (14.1%) cases, which revealed grade I injury in 13 (3.7%), grade II in 23 (6.6%), and grade III in 13 (3.7%) cases. 3.6. Outcomes 28 (8%) cases had died (2.9% in < 24 hours of admission) and 28 (8%) cases were discharged against medical advice. The mean duration of hospital stay was 5.76 ± 6.76 (1 – 50) days. 3 (0.9%) acute renal insufficiency, 5 (1.4%) gastrointestinal per- foration, 33 (9.5%) stricture formation, and 3 (0.9%) fistula formation cases were among the most important complica- tions in the present series. 3.7. Need for ICU admission 53 (15.2%) were admitted to the ICU for 6.32 ± 6.12 days (1 – 41). Table 3 shows the correlation of different demographic, clinical, and endoscopic variables with need for ICU admis- sion. There were a significant correlation between suicidal intention (p < 0.0001), higher grade of mucosal injury on EGD (p < 0.0001), volume of ingestion (p < 0.0001), delayed ad- mission (p = 0.033), level of consciousness on admission (p = 0.001), serum pH on admission (p = 0.003), respiratory rate on admission (p = 0.035), and dyspnea (p < 0.0001) with need for ICU admission. 3.8. Need for surgery 115 (33%) cases were in need of surgical interventions and underwent surgery. Acidic caustic agent (p = 0.027), suicidal intention (p < 0.0001), higher grade of mucosal injury on EGD (p < 0.0001), volume of ingestion (p = 0.010), level of con- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com A. Alipour Faz et al. 4 Table 3: Correlation of demographic, clinical, laboratory, and endoscopic variables with need for ICU admission Variable ICU admission P value No Yes Sex Male 158 (81.9) 35 (18.1) 0.101 Female 136 (88.3) 18 (11.7) Type of caustic agent Alkaline 164 (87.2) 24 (12.8) 0.114 Acidic 122 (81.9) 27 (18.1) Intention Accidental 100 (95.2) 5 (4.8) < 0.001 Suicidal 165 (80.1) 41 (19.9) History of psychiatric disease Yes 53 (73.6) 19 (26.4) 0.068 No 30 (90.9) 3 (9.1) Esophageal injury (endoscopic) Grade I 127 (95.5) 6 (4.5) Grade IIa 31 (83.8) 6 (16.2) < 0.001 Grade IIb 13 (81.3) 3 (18.8) Grade IIIa 34 (54.0) 29 (46) Gastric injury (endoscopic) Grade I 68 (94.4) 4 (5.6) Grade IIa 56 (90.3) 6 (9.7) Grade IIb 23 (71.9) 9 (28.1) < 0.001 Grade III 27 (69.2) 12 (30.8) Grade IV 0 (0.0) 1 (100) Serum pH on admission < 7.35 62 (72.9) 23 (27.1) 7.35 – 7.45 120 (90.2) 13 (9.8) 0.003 > 7.45 33 (84.6) 6 (15.4) Dyspnea Yes 18 (64) 35 (36) < 0.001 No 258 (88.1) 35 (11.9) Mean age (year) 37.19 ± 17.86 40.92 ± 16.00 0.160 Delayed admission (hour) 3.37 ± 3.98 4.76 ± 5.1 0.033 Volume of ingestion 96.16 ± 90.03 165.57 ± 131.03 < 0.001 Glasgow coma scale on admission 14.85 ± 0.55 13.91 ± 2.21 0.001 Respiratory rate (/minute) 18.85 ± 4.57 20.52 ± 6.91 0.035 Data were presented as mean ± standard deviation or number and percentage. sciousness on admission (p = 0.0001), serum pH on admis- sion (p = 0.001), respiratory rate on admission (p < 0.0001), and dyspnea (p = 0.001) were significantly associated with need for surgery. 3.9. Mortality Table 4 shows the correlation of different demographic, clin- ical, and endoscopic variables with mortality. There were a significant correlation between mean age (p = 0.032), suici- dal intention (p = 0.002), higher grade of mucosal injury on EGD (p < 0.0001), volume of ingestion (p = 0.001), level of consciousness on admission (p < 0.001), serum pH on admis- sion (p < 0.001), and respiratory rate on admission (p < 0.001) with mortality. 4. Discussion: Based on the findings of present study, most cases of caus- tic ingestion were between 18 – 35 year old (42%), with 80% female to male ratio, 79% alkaline to acid ratio, 50% un- intentional to intentional ratio, and normal to grade I mu- cosal injury. Suicidal intention, higher grade of mucosal in- jury, higher volume of ingestion, lower level of conscious- ness, lower serum pH, and higher respiratory rate were sig- nificantly correlated with need for ICU admission, need for surgery, and mortality. The sex and age distribution of the study participants were compatible with the results of Paudyal et al. in Nepal (16) and unmatched with the find- ings of Istanbul study which declared the 3:1 female to male ratio of caustic ingestion (17). In this survey, alkaline sub- stances had a higher prevalence compared to acidic solu- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com 5 Emergency. 2017; 5 (1): e56 Table 4: Correlation of demographic, clinical, laboratory, and endoscopic variables with mortality Variable Mortality P value No Yes Sex Male 179 (92.7) 14 (7.3) 0.557 Female 410 (90.9) 14 (9.1) Type of caustic agent Alkaline 173 (92.0) 15 (8.0) 0.844 Acidic 136 (91.3) 13 (8.7) Intention Accidental 103 (98.1) 2 (1.9) 0.002 Suicidal 182 (88.3) 24 (11.7) History of psychiatric disease Yes 61 (84.7) 11 (15.3) 0.771 No 29 (87.9) 4 (12.1) Esophageal injury (endoscopic) Grade I 130 (97.7) 3 (2.3) Grade IIa 36 (97.3) 1 (2.7) < 0.0001 Grade IIb 14 (87.5) 2 (12.5) Grade IIIa 48 (76.2) 15 (23.8) Gastric injury (endoscopic) Grade I 72 (100) 0 (0.0) Grade IIa 57 (91.9) 5 (8.1) Grade IIb 31 (96.9) 1 (3.1) < 0.0001 Grade III 27 (69.2) 12 (30.8) Grade IV 0 (0.0) 1 (100) Serum pH on admission < 7.35 66 (77.6) 19 (22.4) 7.35 – 7.45 128 (96.2) 5 (3.8) <0.001 > 7.45 38 (97.4) 1 (2.6) Delayed admission (hour) 3.59 ± 4.28 3.48 ± 2.88 0.899 Mean age (year) 37.15 ± 17.36 44.61 ± 19.37 0.032 Volume of ingestion 101.68 ± 95.73 178.16 ± 134.53 0.001 Glasgow coma scale on admission 14.85 ± 0.62 13.17 ± 2.56 < 0.001 Respiratory rate (/minute) 18.71 ± 4.41 23.68 ± 8.34 < 0.001 Data were presented as mean ± standard deviation or number and percentage. tions. Arevalo-Silva et al. also reported the predominance of alkaline substance in their study (1). The reason for in- gestion was also found to be intentional in the majority of patients, which was associated with severe injuries. These findings were similar to Cheng et al. study (18). Based on the endoscopic findings, most patients (42.5%) had grade I mucosal injury in their esophagus and stomach, which was congruent with the findings of Arevalo-Silva et al. (1). There are numerous studies on characteristics of caustic in- gestions and predictors of their poor outcome. Endoscopic grading of mucosal damage is reported as a helpful tool in this regard (19). Cheng and their colleagues in the study of adult caustic ingestion showed the correlation of grade IIIb mucosal damage with higher morbidity rate (18). Delayed admission was associated with higher need for ICU admission in the present study. Yeganeh and their colleagues showed that early admission can reduce the mortality rate of corrosive ingestion (20). Older age had been associated with poorer clinical outcome in patients with caustic ingestion (21). Caustic ingestion with suicidal intention was correlated with higher rate of mortal- ity and poorer outcome (22). In addition, acid ingestions were associated with severe com- plication and higher mortality rate than alkaline in some studies (22-24). Lower serum pH is reported as an indica- tor of severe injury in blood gas analysis of caustic ingestion cases (25). In this survey, 42.5% of patients were discharged from hospi- tal after two days of hospitalization in observation unit and 15.2% of the patients were admitted to the ICU. One third of patients needed surgery and underwent laparotomy, gastro- tomy, biopsy, stent placement, and feeding jejunostomy. Collectively, based on the study findings, it seems that the main predictor of poor outcome in caustic cases is intention type. If caustic ingestion happens with suicidal attempt, it would be linked with higher volume, high potent solution, This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com A. Alipour Faz et al. 6 and delayed admission, all of which are indicators of poorer outcomes. Planning for preventive measures may seem ineffective in intentional cases, but it would be very helpful in decreas- ing the unintentional ones. Using cleaning and detergent agents with safe formula and keeping them away from chil- dren could be considered for minimizing the severity and number of unintentional cases. 5. Limitations This is a retrospective cross-sectional study with its natural limitations that missing data is among the most important of them. 6. Conclusion: It seems that, suicidal intention, higher grade of mucosal in- jury, higher volume of ingestion, lower level of conscious- ness, lower serum pH, and higher respiratory rate are among the most important predictors of need for ICU admission, need for surgery, and mortality. 7. Appendix 7.1. Acknowledgements The authors appreciate the support of Clinical Research De- velopment Center of Loghman Hakim Hospital, Shahid Be- heshti University of Medical Sciences, Tehran, Iran. 7.2. Author contribution All authors passed four criteria for authorship contribution based on recommendations of the International Committee of Medical Journal Editors. 7.3. Funding/Support None. 7.4. Conflict of interest None. References 1. ArevaloâĂŘSilva C, Eliashar R, Wohlgelernter J, Elidan J, Gross M. Ingestion of caustic substances: a 15âĂŘyear experience. The Laryngoscope. 2006;116(8):1422-6. 2. Bronstein AC, Spyker DA, Cantilena Jr LR, Green JL, Ru- mack BH, Heard SE. 2007 annual report of the American Association of Poison Control Centers’ National poison data system (NPDS): 25th Annual report. Clinical Toxicol- ogy. 2008;46(10):927-1057. 3. Elshabrawi M, A-Kader HH. Caustic ingestion in chil- dren. Expert review of gastroenterology & hepatology. 2011;5(5):637-45. 4. Mowry JB, Spyker DA, Brooks DE, McMillan N, Schauben JL. 2014 Annual Report of the American Association of Poison Control Centers’ National Poison Data Sys- tem (NPDS): 32nd Annual Report. Clinical toxicology. 2015;53(10):962-1147. 5. Rollin M, Jaulim A, Vaz F, Sandhu G, Wood S, Birchall M, et al. Caustic ingestion injury of the upper aerodigestive tract in adults. Annals of the Royal College of Surgeons of England. 2015;97(4):304. 6. Kikendall J. Caustic ingestion injuries. Gastroenterology Clinics of North America. 1991;20(4):847-57. 7. Riffat F, Cheng A. Pediatric caustic ingestion: 50 consec- utive cases and a review of the literature. Diseases of the Esophagus. 2009;22(1):89-94. 8. Haller Jr A, Gibbs Andrews H, White JJ, Akram Tamer M, Cleveland WW. Pathophysiology and management of acute corrosive burns of the esophagus: results of treatment in 285 children. Journal of pediatric surgery. 1971;6(5):578-84. 9. Thompson JN. Corrosive esophageal injuries I. A study of nine cases of concurrent accidental caustic ingestion. The Laryngoscope. 1987;97(9):1060-8. 10. Thompson JN. Corrosive esophageal injuries. II. An in- vestigation of treatment methods and histochemical analysis of esophageal strictures in a new animal model. The Laryngoscope. 1987;97(10):1191-202. 11. Zargar SA, Kochhar R, Mehta S, Mehta SK. The role of fiberoptic endoscopy in the management of corrosive in- gestion and modified endoscopic classification of burns. Gastrointestinal endoscopy. 1991;37(2):165-9. 12. Brunicardi F, Andersen D, Billiar T, Dunn D, Hunter J, Matthews J, et al. Schwartz’s Principles of Surgery, 10th edition: McGraw-Hill Education; 2014. 13. Campbell GS, Burnett HF, Ransom JM, Williams GD. Treatment of corrosive burns of the esophagus. Archives of Surgery. 1977;112(4):495. 14. Haller JA, Bachman K. The comparative effect of current therapy on experimental caustic burns of the esophagus. Pediatrics. 1964;34(2):236-45. 15. Hill JL, Norberg HP, Smith MD, Young JA, Reyes HM. Clin- ical technique and success of the esophageal stent to prevent corrosive strictures. Journal of pediatric surgery. 1976;11(3):443-50. 16. Paudyal B. Poisoning: pattern and profile of admitted cases in a hospital in central Nepal. JNMA J Nepal Med Assoc. 2005;44(159):92-6. 17. Tufekci IB, Curgunlu A, Sirin F. Characteristics of acute adult poisoning cases admitted to a university hos- pital in Istanbul. Human & experimental toxicology. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com 7 Emergency. 2017; 5 (1): e56 2004;23(7):347-51. 18. Cheng H-T, Cheng C-L, Lin C-H, Tang J-H, Chu Y-Y, Liu N-J, et al. Caustic ingestion in adults: The role of en- doscopic classification in predicting outcome. BMC Gas- troenterology. 2008;8(1):31. 19. Cabral C, Chirica M, de Chaisemartin C, Gornet J-M, Munoz-Bongrand N, Halimi B, et al. Caustic injuries of the upper digestive tract: a population observational study. Surgical endoscopy. 2012;26(1):214-21. 20. Yeganeh R, Peyvandi H, Mohajeri M, Bashtar R, Bashashati M, Ahmadi M. Investigation of mortality after corrosive ingestion: A prospective study. Acta Medica Iranica. 2009;47(1):15-9. 21. Chang J-M, Liu N-J, Pai BC-J, Liu Y-H, Tsai M-H, Lee C-S, et al. The Role of Age in Predicting the Outcome of Caus- tic Ingestion in Adults: A Retrospective Analysis. BMC Gastroenterology. 2011;11(1):72. 22. Ertekin C, Alimoglu O, Akyildiz H, Guloglu R, Taviloglu K. The results of caustic ingestions. Hepato- gastroenterology. 2003;51(59):1397-400. 23. Poley J-W, Steyerberg EW, Kuipers EJ, Dees J, Hartmans R, Tilanus HW, et al. Ingestion of acid and alkaline agents: outcome and prognostic value of early upper endoscopy. Gastrointestinal Endoscopy. 2004;60(3):372-7. 24. Ducoudray R, Mariani A, Corte H, Kraemer A, Munoz- Bongrand N, Sarfati E, et al. The Damage Pattern to the Gastrointestinal Tract Depends on the Nature of the Ingested Caustic Agent. World journal of surgery. 2016;40(7):1638-44. 25. Cheng Y-J, Kao E-L. Arterial Blood Gas Analysis in Acute Caustic Ingestion Injuries. Surgery Today. 2003;33(7):483-5. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com Introduction Methods Results Discussion: Limitations Conclusion: Appendix References